16
Dental
Orthodontia (up to age 19)
Coverage amounts based on in-network providers. If you use
an out-of-network provider, you may pay more.
Eligibility: All Team Members and dependents
You pay 50%
Lifetime maximum paid
by plan: $1,500.
Annual Deductible
$50/individual
(waived for preventive services)
Diagnostic and Preventive
Services (100% covered)
• Oral exams/cleaning
(two per 12 months)
• Fluoride treatments
(under age 16)
• X-rays, bitewings
(once per year)
• Space maintainers
(to age 16)
Routine Services
For example, fillings and extractions
You pay 20% after deductible.
Major Services
For example, dentures, crowns, bridges,
and wisdom teeth removal
You pay 50% after deductible.
Maximum payout: $1,500 per
covered person per year.
Team Member
only
Team Member
+ Child(ren)
Team Member
+ Spouse
Family
Weekly Cost of Dental Coverage
$6.40 $11.77 $11.77 $16.22